13 Feb Strengthening the Home Health–to–Hospice Continuum
Strategies to Improve Referral Conversion While Maintaining Clinical Integrity
The transition from home health to hospice represents one of the most fragile points in the care continuum. Despite a six‑month hospice benefit, nearly half of hospice patients are enrolled for 30 days or less, causing them to miss the relationship‑building, interdisciplinary support, and memory‑making that characterize what many describe as “the beauty of hospice.” Ineffective or fragmented transitions often result in unclear responsibility, inconsistent messaging, delayed care, and preventable rehospitalizations.
Continuity is more than an operational marker, as it directly influences clinical outcomes and patient and family experience. Administrators are uniquely positioned to develop systems that transform fragmented handoffs into streamlined and clinically aligned care pathways (CMS, 2023; NHPCO, 2022).
Fragmentation and Communication Gaps
Fragmentation frequently emerges when multiple clinicians and agencies (i.e., home health, hospice, hospitals, assisted‑living facilities, and primary care) contribute to a patient’s care. Without reliable information flow, patients and families often struggle to understand who is responsible for what. Poorly communicated care plans can delay symptom reporting and lead to avoidable crises. Hospice care consultants often share stories of encountering referrals only when patients are on the verge of calling 911 due to escalating pain, nausea, or dyspnea – symptom progressions that could have been anticipated had documentation and communication been standardized.
Lack of Standardized Clinical Assessment and Eligibility Communication
Without a structured home‑health‑to‑hospice program, documentation practices vary widely, particularly around goals of care, disease trajectory, and caregiver readiness. When notes lack standardized terminology, outside clinicians may overlook indicators of hospice eligibility. Literature on patient‑reported outcomes and experience measures (PROMs/PREMs) shows that poor transitions produce uncertainty, medication confusion, and unmet needs (AHRQ, 2021). Standardized documentation offers a foundation for timely identification of hospice needs.
Operational Barriers
Administrators frequently face barriers linked to the discharge process. Hospice admission cannot proceed until home health discharges the patient, or billing conflicts may occur. If discharge occurs the same day, some agencies agree to a non‑billable discharge, but inconsistent expectations can cause delays or overlap. Clear workflows are essential to avoid gaps or duplication of care. This also applies to transition in vendors for durable medical equipment that must occur from home health to hospice, and ensuring families are made aware of the switch.
Caregiver Burden and Patient Confusion
Families often become de facto care coordinators and may experience distress, fear, or delay in seeking help due to inconsistent communication. This emotional load contributes to crisis‑driven transitions instead of planned, goal‑oriented care transitions.
Affiliation *Can* Matter
Medicare data show that patients under hospice‑affiliated home health agencies enroll in hospice at significantly higher rates, suggesting that familiarity and continuity reduce resistance to transitioning (MedPAC, 2023). Strong partnerships enhance community care, decrease readmissions, and create predictable pathways that benefit both patients and providers.
Strategies for Building a High‑Integrity Care Continuum
1) Standardize Documentation
A unified documentation template should capture clinical trajectory, symptom burden, psychosocial needs, caregiver capacity, and provider contacts (ALF, PCP, specialized MD, etc.). Color‑coded statuses can indicate clinical eligibility, decision stage, and barriers to care.
2) Form a Care Transitions Team
A dedicated team—nurses, social workers, and leadership—can serve as a single point of contact for both home health and hospice, reducing fragmentation and ensuring clear oversight. This team reviews templates and home health notes, flags declining patients, and participates in case conferences.
3) Implement an Outreach and Communication Log
A centralized log should track every communication, barrier, and decision factor, enabling immediate updates during interdisciplinary meetings across home health, assisted‑living partners, and physician groups.
4) Driving Referral Conversion Without Compromising Clinical Integrity
The first call with a patient or caregiver shapes expectations. When staff are trained to ask clinically informed questions, recognize distress signals, and clearly articulate hospice philosophy, start‑of‑care rates improve and delays shrink. Conversations should reinforce hospice as an added support layer rather than “giving up”, as well as highlight potential compatibility with certain treatments under open‑access models.
5) Data Analysis to Track Patterns
Data should be used to identify families repeatedly declining hospice, clinicians with inconsistent eligibility understanding, and diagnoses associated with late entry (i.e. dementia vs. cancer diagnoses). Such insights have the power to improve workflows and outreach timing.
6) Ensuring Billing Integrity and Avoiding Overlaps
Agencies must coordinate discharge and admission timing and educate staff on CMS rules. When home health continues for conditions unrelated to hospice’s primary diagnosis, documentation should clearly delineate responsibilities. Avoiding overlaps enhances compliance and care clarity.
Operational Excellence: Building a Seamless Handoff
Home health clinicians can introduce hospice early by discussing disease progression, equipment expectations, and supportive services available through hospice. Anticipatory guidance prepares families and reduces crisis‑driven decisions.
Shared Data and Technology
Real‑time data sharing between agencies, i.e. with the use of tools often found in hospice software such as logs and trackers which display symptom escalation, frequent visits, or hospitalizations, can allow for timely intervention and prevent rehospitalizations. Remote visibility into care transitions supports rapid coordination when condition changes may occur.
Case Example: Implementing Standardization to Increase Conversion
A small hospice site (< 100 patients) implemented standardized templates and a color‑coded tracking system to capture eligibility indicators and patient decision stages. A centralized outreach log supported consistent messaging across home health, hospice, assisted‑living facilities, and physician partners. This standardized approach improved case‑conference responsiveness and increased referral‑to‑admission conversion by 25%. The subsequent addition of a care transitions team as bridge between the affiliated home health and hospice teams then further advanced the ability to proactively identify and support eligible patients.
Why This Work Matters
High‑quality transitions reduce emotional distress, preserve dignity, and prevent avoidable hospital utilization. For many patients, home is the preferred setting for end‑of‑life care. Early conversations foster autonomy, values‑based decision‑making, and time for families to reflect, grieve, and prepare. A robust continuum enables patients to stay aligned with their goals of care and express their priorities.
Key Strategies for Immediate Implementation
• Establish a unified care‑transition workflow with home health partners.
• Create a standardized trajectory and eligibility template and communication log.
• Hold weekly multidisciplinary reviews of identified declining patients.
• Train intake staff in clinically aligned communication.
• Use early values‑based conversations to prevent last‑minute admissions.
• Audit overlaps monthly for billing and compliance integrity.
The Take Away
A seamless transition from home health to hospice relies on operational rigor, clinical alignment, and transparent communication. When executed effectively, these transitions enhance outcomes, reduce hospital utilization, elevate patient and family experience, and promote appropriate hospice use. Administrators who invest in structured pathways and multidisciplinary collaboration strengthen referral conversion while upholding clinical integrity, which are key pillars of a modern care continuum.
Author’s Note: Views, information, and guidance in this resource are intended for information only. We are not rendering legal, financial, accounting, medical, or other professional advice. Alora disclaims any liability to any third party and cannot make any guarantee related to the content.
References
Agency for Healthcare Research and Quality. (2021). Care transitions and patient experience.
Centers for Medicare & Medicaid Services. (2023). Hospice utilization and quality reporting.
Medicare Payment Advisory Commission. (2023). Report to Congress: Medicare payment policy.
National Hospice and Palliative Care Organization. (2022). Facts and figures on hospice care.
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